REQUEST FOR REISSUED IRS FORM W-2
PLEASE PRINT AND SEND OR FAX TO:
3000 Rockefeller, MS 610 PHONE: (425) 388-3401
Everett WA 98201 FAX: (425) 388-3744
Please reissue a WAGE AND TAX STATEMENT - FORM W-2 for the tax year(s):
Social Security No. (last 4 digits only) XXX-XX-
City: State: Zip Code:
Delivery Method (select one): NOTE: If no selection is made we will mail
the form to the address on file.
Pick up Picture ID required to pick up.
Sent to Dept Department Name:
The FORM W-2 is requested for the following reason:
Misplaced or Destroyed
Social Security Number incorrect (see below) *
Name incorrect (see below) *
* If your Social Security Number or name is incorrect, we will need a copy of your
Social Security card to verify the correct information.
FOR PAYROLL DEPT USE ONLY:
Date request rec'd: Original W-2 remailed:
Processed by: Duplicate W-2 reissued: